■ The AMA opposes the mandate but supports a voluntary system with adequate financial incentives.

Washington -- A war of words escalated earlier this month when a group of pharmacy benefit managers increased the pressure on Congress to pass what the American Medical Association warned would be a costly Medicare electronic prescribing requirement for physicians.

The Pharmaceutical Care Management Assn. since the summer has been pushing lawmakers to include an e-prescribing mandate in any legislation to prevent next year's 10.1% Medicare physician pay cut. Now the PCMA has launched a tough television and print advertising campaign.

"The time for debates and studies is over. Washington needs to require e-prescribing in Medicare before more people die," the speaker on the TV spot says.

The reference is to last year's Institute of Medicine recommendation that all physicians embrace e-prescribing by 2010. The goal is to help reduce the estimated 1.5 million medication errors and 7,000 patient deaths that occur annually. The speaker in the ad is J. Lyle Bootman, PhD, ScD, the dean of the University of Arizona College of Pharmacy and chair of the IOM panel that studied the issue.

PCMA also started running a print advertisement directed at lawmakers. "While you wait, thousands die each year," begins the ad. It states that an e-prescribing mandate is needed in Medicare because seniors constitute many of the deaths.

The AMA supports using e-prescribing to help improve patient safety but says that an unfunded mandate would be the wrong approach. In Oct. 31 letters to Sen. John Kerry (D, Mass.) and Rep. Allyson Schwartz (D, Pa.), the AMA called for e-prescribing legislation that combines voluntary adoption with robust federal funding for those who decide to use the technology. The two lawmakers have expressed an interest in taking the lead on Medicare e-prescribing legislation.

Without the ability to opt out or the financial support to make the transformation, many physician practices would face a great burden under an e-prescribing mandate, wrote AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, in the letters to Kerry and Schwartz.

"Over 50% of physician practices have five physicians or less, and they provide approximately 80% of all outpatient visits," he wrote. "The costs for such small practices of e-prescribing technology, training and upgrades are significant."

Congress must also press the Dept. of Health and Human Services to complete e-prescribing standards that would convince doctors their technology investments "will not be rendered obsolete overnight," Dr. Maves stated.

Complicating the pay debate

The electronic prescribing disagreement has added a twist to Congress' debate over Medicare physician payment this year.

The AMA cited the upcoming drastic payment cut in resisting the proposed requirement for doctors, saying that physicians should especially not face such a burden in a year when their pay is set to go down by 10.1%. The pharmacy benefit managers, on the other hand, said that congressional action committing billions to reverse the pay reduction would be the perfect opportunity for promoting e-prescribing to save Medicare billions, in addition to saving lives.

Requiring physicians and pharmacies to handle all Medicare drug orders electronically by 2010 would reduce federal health care costs by nearly $30 billion and prevent 1.6 million adverse drug events over the next decade, according to a July study commissioned by PCMA.

Pharmacy benefit managers, which administer drug benefits for Medicare and most private plans, in turn would reap savings by encouraging greater use of mail-order services and through other efficiency gains.

The AMA has noted, however, that the Congressional Budget Office has not identified any potential federal savings from a Medicare e-prescribing mandate. The Association opposes the PCMA plan.

At press time in mid-November, Senate Finance Committee leaders working on Medicare physician payment legislation had not ruled out e-prescribing provisions, according to congressional aides. The House is sticking with its previously approved language, which calls for two years of positive pay updates and does not include an e-prescribing requirement.

This is not the first year that an e-prescribing requirement has come up on Capitol Hill. Lawmakers in 2003 considered adding a mandate to the legislation authorizing the Medicare drug benefit, but they withdrew the proposal under pressure from organized medicine. Drug plan sponsors are now required to accept electronic drug orders, but PCMA estimates that fewer than one in 10 doctors have taken advantage of the option.

The benefit managers group showed little sign of letting up on the issue even if lawmakers do not act quickly enough to include a mandate on Medicare pay legislation before the end of the congressional session. The group will keep up the pressure on Congress until an e-prescribing requirement is approved because it is the right thing to do from a policy standpoint, said PCMA President and CEO Mark Merritt.

No matter what happens this session, some physicians will be able to receive more Medicare dollars starting next year if they decide to issue electronic prescriptions under Part D.

The Centers for Medicare & Medicaid Services added electronic prescribing for Medicare patients to the list of quality measures in its voluntary Physician Quality Reporting Initiative for 2008. Under most circumstances, a doctor who meets this requirement and at least two other measures will be eligible for a bonus of up to 1.5% of all Medicare payments for the year.

CMS listed the e-prescribing measure in the final physician payment rule that also finalized the 10.1% cut that will go into effect Jan. 1, 2008, if Congress does not act first.